Babies with Jaundice

Jaundice tends to be more common in breastfed babies and to last a bit longer. In most cases, it's harmless, but jaundice phobia on the part of parents and healthcare providers often creates obstacles to successful breastfeeding. Here's some background on jaundice and ways to minimize interference with breastfeeding.

Jaundice (also known as hyperbilirubinemia) is the cause of the yellow tinge that colors the skin and eyeballs of newborn infants, especially in the first week or two. Jaundice happens because babies are born with more red blood cells than they need. When the liver breaks down these excess cells it produces a yellow pigment called bilirubin. Because the newborn's immature liver can't dispose of bilirubin quickly, the excess yellow pigment is deposited in the eyeballs and skin of the newborn.

This kind of a jaundice is called physiologic jaundice, because it is part of a normal body process. Once the newborn's bilirubin-disposal system matures and the excess red blood cells diminish, the jaundice subsides – usually within a week or two – and causes baby no harm. Jaundice is more common in premature infants, who are less able to cope with excess bilirubin.

In some situations, such as an incompatibility of blood types between mother and baby, jaundice may be the result of problems that go beyond the normal breakdown of excess red blood cells. In rare instances, the bilirubin levels can rise high enough to damage baby's brain. For this reason, if the healthcare provider suspects that something more than normal physiologic jaundice is the cause of baby's yellow color, bilirubin levels will be monitored more closely, using blood samples. If the bilirubin level gets too high, your doctor may try to lower the bilirubin level using phototherapy, special lights which dissolve the extra bilirubin in the skin, allowing it to be excreted in the urine.

Bilirubin levels average 2-3 milligrams higher in breastfed infants than in formula-fed infants (14.8 milligrams versus 12.4 milligrams). The difference is thought to be due to an as-yet unidentified factor in breastmilk that promotes increased intestinal absorption of bilirubin, so that it goes back into the bloodstream rather than moving on to the liver. Higher rates of jaundice in breastfed infants may also be related to lower milk intakes in the first days after birth, because of infrequent or inefficient feeding. It is normal for jaundice to last a bit longer in breastfeeding infants, sometimes until the third week after birth.

While most newborn jaundice is harmless, common medical remedies for jaundice can interfere with getting breastfeeding off to a good start. Therefore, healthcare providers and parents should be cautious about treating a condition in which the cure can create more problems than the disease. Watch out for what we call the "yellow flags" that signal an overreaction to jaundice in the breastfeeding baby.

• In most cases, it is not necessary to treat jaundice when bilirubin levels are less than 20 milligrams.
• Most jaundiced infants do not need supplements of water, sugar water or formula.
• Avoiding breastfeeding for a day or two is not usually necessary to bring down bilirubin levels.
• Shake off any suggestion that something about your milk is bad for your baby. As long as your baby is otherwise healthy, jaundice is short-lived and harmless. If your baby's jaundice is related to other health problems, your milk is very valuable for him and you should continue to breastfeed.

Lowering baby's bilirubin levels also helps to lower the worry level of both parents and healthcare providers. The things you do to get breastfeeding off to a good start will also help you avoid problems with jaundice.

• Early, frequent, unrestricted breastfeeding helps to eliminate bilirubin from baby's body. Bilirubin exits the body in the infant's stools, and because breastmilk has a laxative effect, frequent breastfeeders tend to have lots of soiled diapers and thus, lower bilirubin levels.
• Be sure that your baby is latched on well and is sucking efficiently. See "Latch-on basics" and "Signs of efficient latch" for tips on getting baby to nurse well.
• Jaundice sometimes makes babies sleepy, so they nurse less enthusiastically. You may have to take the lead and wake your baby during the day to encourage her to nurse. See "Waking the sleepy baby" for suggestions.
• If phototherapy treatment is necessary because of a high bilirubin level, talk to your healthcare provider about alternatives to placing baby in the hospital nursery under phototherapy lights. For most babies a photo-optic bilirubin-blanket (phototherapy lights that wrap around the baby) works well. You can hold and breastfeed your baby at home while the lights dissolve the bilirubin.
• Giving breastfed babies bottles of sugar water in hopes of reducing bilirubin levels has been shown to be ineffective. It may even aggravate the jaundice, because babies whose tummies are full of glucose solutions may nurse less often, reducing their milk intake and the opportunities for bilirubin to be excreted in stools.
• If your doctor advises giving formula supplements to provide more fluids and calories and decrease the intestinal absorption of bilirubin, work with a lactation consultant to give supplements via a supplementary nursing system, syringe, or finger-feeding methods. See "Alternatives to bottles". This will avoid problems with nipple confusion.
• Don't worry, make milk. If your baby is jaundiced, be sure you understand what type of jaundice your baby has. If it's normal physiologic jaundice, you have absolutely nothing to worry about. If it's jaundice due to a medical cause, such as a blood group incompatibility, be sure you understand that this is easily treated and should not interfere with your breastfeeding. Worry may cause you to make less milk and doubt your ability to nourish your baby at the breast. This gets in the way of breastfeeding success.

In some breastfed babies, bilirubin levels may exceed 20 milligrams and jaundice may last well into the second week of life or longer. It was once thought that this was a distinct type of jaundice, called breast milk jaundice, that was found in a small group of mothers whose milk contained a substance believed to interfere with bilirubin absorption. Treatment for this type of jaundice involved taking baby off the breast for 24 to 48 hours. This brought bilirubin levels down, but sabotaged the course of breastfeeding.

More recent research suggests that high bilirubin levels and prolonged jaundice in otherwise healthy breastfed babies are just normal variants of ordinary physiologic newborn jaundice. There may well be a substance in the milk of most mothers that inhibits the absorption of bilirubin by the intestines, but whether a baby has a little jaundice or a lot is largely due to individual differences in both babies and mothers.

Nevertheless, some healthcare providers may suggest a period of temporary weaning (24 to 48 hours) to bring down bilirubin levels. Work with your doctor to determine if there are other alternatives, for example, phototherapy, that would allow breastfeeding to continue without restrictions. If you do decide to try formula for a day or two, be sure to pump your breasts every two to three hours so that you will continue to make milk and avoid a breast infection. Formula supplements can be given using alternatives to bottles, to avoid problems with nipple confusion when baby returns to the breast.